“I [have been applying] for a permit since October 2016. I asked about the permit 6 times but I was told that it was under security check. It was rejected,” says Shayma, 25 (who preferred to use a pseudonym), from the Gaza Strip, who suffers from a malignant brain tumour in the skull and cervical region. She was treated for six sessions of chemotherapy in Gaza but her cancer recurred again. As Gaza does not have radiotherapy, Shayma has to make her way to East Jerusalem for treatment.

The plight of Shayma echoes that of many other cancer patients from Gaza who had to go through a lengthy and arduous process in order to seek specialised medical treatment, mostly in Israel or East Jerusalem.

Every month, about 1,500 Gaza patients travel to the West Bank, East Jerusalem, Israel, or Egypt to receive medical treatment and other services not available in Gaza. As part of the movement restrictions Israel imposes on residents of the Strip, Palestinians from Gaza need special Israeli-issued permits in order to travel to Israel or to the West Bank for treatment.

As well as 50 years of Israeli occupation, 2017 marks 10 years since Hamas took control of Gaza after a sweeping win at the 2006 legislative elections. Israel, which considers Hamas a terrorist organisation, imposed a crippling air, ground and sea blockade on the small territory which, over a decade, has severely affected its economy, environment and every aspect of daily life. After the 2014 war, the UN warned that should the status quo be allowed to continue, Gaza will become uninhabitable by 2020.

The World Health Organisation(WHO) recently reported that permit approval rates for Gazans who wish to travel to Israel and the Occupied Palestinian Territories for specialised medical treatment have been dropping steadily: from 92.5% in 2012 to 88.7% in 2013, 82.4% in 2014 to 77.5% in 2015 and by October 2016, the approval rate had fallen drastically to 44%. Of 2,792 patient applications for a permit to exit Gaza through Erez checkpoint for hospital appointments in January 2017, more than half were denied.

There are numerous obstacles which cancer patients encounter when they travel via the Erez crossing to the designated hospitals for treatment.

“Cancer patients’ suffering start the moment they lack their treatment in the Gaza Strip,” Samir Al Mana’ma, a lawyer at Al Mezan Center for Human Rights in Gaza told Palestine Monitor. “They first obtain a medical referral from the Palestinian Ministry of Health to a hospital in Israel or the West Bank. This referral takes about three and a half months to be ready," Al Mana'ma explained.

Ever since the blockade imposed on Gaza by Israel in 2007, its economy suffered adverse impact. Gaza’s health care system has also been hard-hit by this policy. The blockade resulted in the lack of up-to-date facilities, equipment and expertise.

In the past few weeks, Gaza has also witnessed an exacerbation of its electricity crisis, which left residents with only four hours of electricity a day, down from its normal schedule of eight hours on, eight hours off. This week, the Israeli security cabinet approved a 40 percent reduction in Israel’s electricity supply to Gaza in response to a request by the PA last month, which is bound to worsen the already dire crisis.

Dr. Omar Abdul Shafi, who is a colon, breast and thyroid cancer specialist at the Augusta Victoria Hospital, told Palestine Monitor that Gaza does not have radiotherapy, and certain chemotherapy agents are not available in the Strip.

“Some surgical procedures are not being done because of a lack of certain materials,” Dr. Shafi added. Israel restricts the entry of so-called “dual use” materials into Gaza – materials that the Israeli government fears could be used for both civilian and military purposes. However, NGOs working in Gaza argue the list should be reviewed, and have often complained they are unable to import materials needed to implement, for instance, waste and sanitation projects.

Crossing the Erez checkpoint for treatment in Israel and the occupied West Bank is the most viable option for Gaza's severely ill patients, such as those needing cancer treatment. But the path is riddled with obstacles such as delays and denials of permits.

Going to Egypt for treatment is another option, but the Rafah border has been mostly closed since the ouster of Morsi in 2013.

Samir Al Mana’ma adds that Israeli responses to the requests are usually negative. “[Most of] the requests are still under study or rejected and patients are being summoned to meet the Israeli intelligence at Erez Crossing. Moreover, the Israeli authorities give no clear reasons for their responses to patients,” he said.

For many cancer patients awaiting treatment in Israel, the refusal of permits is like meting out a death sentence. Not giving up hope, Shayma consulted a lawyer who finally helped and paved the way for her treatment at the Augusta Victoria Hospital in Occupied East Jerusalem in April 2017.

Shayma is not alone in this predicament. Physicians for Human Rights-Israel (PHRI) has noted a steady increasein the number of cancer patients requesting help in overturning their rejected permits, with 23 requests in 2014 which tripled to 69 in 2016.

Israel’s permit regime has sometimes cost lives. The Al Mezan Center for Human Rights reported last month that Walid Mohamed Mohamed Qa’oud, 59, died of cancer on 2 May after repeated failed attempts to obtain a permit to travel to the Augusta Victoria Hospital in Jerusalem for treatment.

Later that month, Tal’at Mahmoud Sulaiman Al Shawi, a 52-year-old resident of Rafah, was diagnosed with a kidney tumour. Due to delays in receiving the urgently needed medical treatment, the cancer metastised to his spine, causing paralysis of the lower half of his body, Al Mezan reported.

The decision making process of granting travel permits by the Israeli authorities does not seem to be congruent with the severity of each patient’s illness. Dr. Shafi also noted the contradictions in granting permits to cancer patients who should be given priority. “There are cancer patients who are in the early stages of cancer and they get a permit after 2 months while there are some in the advanced stages who obtained the permit much later. This is not a good sign,” Dr. Shafi said.

“The procrastination and the negative responses come in the context of collective punishment which Israel practices against Palestinians in the Gaza Strip,” said Al Mezan's Samir Al Mana’ma.

Physicians for Human Rights, an NGO that uses medicine and science to document human rights abuses around the world, also condemnedthe increased instances of refusals and revocations of permits for Gaza residents on “security grounds”, saying they “represent a step-up in the tightening of Israel’s closure and a means of exerting pressure by harming the most vulnerable in the Strip.”